Comprehensive Profiling of Secreted Factors in the Cerebrospinal Fluid of Moyamoya Disease Patients.

Moyamoya disease (MMD) is characterized by progressive occlusion of the intracranial internal carotid arteries, leading to ischemic and hemorrhagic events. Significant clinical differences exist between ischemic and hemorrhagic MMD. To understand the molecular profiles in the cerebrospinal fluid (CSF) of MMD patients, we investigated 62 secreted factors in both MMD subtypes (ischemic and hemorrhagic) and examined their relationship with preoperative perfusion status, the extent of postoperative angiographic revascularization, and functional outcomes. Intraoperative CSF was collected from 32 control and 71 MMD patients (37 ischemic and 34 hemorrhagic). Multiplex Luminex assay analysis showed that 41 molecules were significantly elevated in both MMD subtypes when compared to controls, including platelet-derived growth factor-BB (PDGF-BB), plasminogen activator inhibitor 1 (PAI-1), and intercellular adhesion molecule 1 (ICAM1) (p < 0.001). Many of these secreted proteins have not been previously reported in MMD, including interleukins (IL-2, IL-4, IL-5, IL-7, IL-8, IL-9, IL-17, IL-18, IL-22, and IL-23) and C-X-C motif chemokines (CXCL1 and CXCL9). Pathway analysis indicated that both MMD subtypes exhibited similar cellular/molecular functions and pathways, including cellular activation, migration, and inflammatory response. While neuroinflammation and dendritic cell pathways were activated in MMD patients, lipid signaling pathways involving nuclear receptors, peroxisome proliferator-activated receptor (PPAR), and liver X receptors (LXR)/retinoid X receptors (RXR) signaling were inhibited. IL-13 and IL-2 were negatively correlated with preoperative cerebral perfusion status, while 7 factors were positively correlated with the extent of postoperative revascularization. These elevated cytokines, chemokines, and growth factors in CSF may contribute to the pathogenesis of MMD and represent potential future therapeutic targets.

Matched-pair analysis of patients with ischemic stroke undergoing thrombectomy using next-generation balloon guide catheters.

BACKGROUND: Balloon guide catheters (BGCs) have not been widely adopted, possibly due to the incompatibility of past-generation BGCs with large-bore intermediate catheters. The next-generation BGC is compatible with large-bore catheters. We compared outcomes of thrombectomy cases using BGCs versus conventional guide catheters. METHODS: We conducted a retrospective study of 110 thrombectomy cases using BGCs (n=55) and non-BGCs (n=55). Sixty consecutive thrombectomy cases in whom the BOBBY BGC was used at a single institution between February 2021 and March 2022 were identified. Of these, 55 BGC cases were 1:1 matched with non-BGC cases by proceduralists, age, gender, stent retriever + aspiration device versus aspiration-only, and site of occlusion. First-pass effect was defined as Thrombolysis In Cerebral Infarction 2b or higher with a single pass. RESULTS: The BGC and non-BGC cohorts had similar mean age (67.2 vs 68.9 years), gender distribution (43.6% vs 47.3% women), median initial National Institutes of Health Stroke Scale score (14 vs 15), and median pretreatment ischemic core volumes (12 mL vs 11.5 mL). BGC and non-BGC cases had similar rates of single pass (60.0% vs 54.6%), first-pass effect (58.2% vs 49.1%), and complications (1.8% vs 9.1%). In aspiration-only cases, the BGC cohort had a significantly higher rate of first-pass effect (100% vs 50.0%, p=0.01). BGC was associated with a higher likelihood of achieving a modified Rankin Scale score of 2 at discharge (OR 7.76, p=0.02). No additional procedural time was required for BGC cases (46.7 vs 48.2 min). CONCLUSION: BGCs may be safely adopted with comparable procedural efficacy, benefits to aspiration-only techniques, and earlier functional improvement compared with conventional guide catheters.

Modern Imaging of Aneurysmal Subarachnoid Hemorrhage.

In this review, we discuss the imaging of aneurysmal subarachnoid hemorrhage (SAH). We discuss emergency brain imaging, aneurysm detection techniques, and the management of CTA-negative SAH. We also review the concepts of cerebral vasospasm and delayed cerebral ischemia that occurs after aneurysm rupture and their impact on patient outcomes. These pathologies are distinct, and the use of multimodal imaging modalities is essential for prompt diagnosis and management to minimize morbidity from these conditions. Lastly, new advances in artificial intelligence and advanced imaging modalities such as PET and MR imaging scans have been shown to improve the detection of aneurysms and potentially predict outcomes early in the course of SAH.

A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment.

BACKGROUND: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care. OBJECTIVE: To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications. METHODS: In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts. RESULTS: Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days ( P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% ( P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay. CONCLUSION: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

A case of recurrent aneurysm resulting from dual antiplatelet plus anticoagulation after confirmed aneurysm closure following coil-assisted flow diversion.

Dual antiplatelet therapy (DAPT) is a management cornerstone for intracranial aneurysms treated with flow diversion. However, combined dual antiplatelet plus anticoagulation (triple therapy) can be indicated in some patients with important associated risks. Here we present the case of a 72-year-old woman with prior history of subarachnoid hemorrhage who was started on triple therapy (enoxaparin and DAPT) following successful flow diversion of an enlarging but unruptured left fetal posterior communicating artery aneurysm. Her post-procedural course was complicated by in-stent thrombosis in the setting of a missed ticagrelor dose and subsequent development of deep venous thrombosis and pulmonary embolism. An early follow-up angiogram confirmed occlusion of the aneurysm. However, after initiation of triple therapy, the aneurysm partially recanalized and her symptoms recurred. Subsequent discontinuation of enoxaparin lead to prompt aneurysm re-occlusion. To our knowledge, this is the first reported instance of confirmed intra-aneurysmal thrombolysis in a successfully treated aneurysm after triple therapy initiation.

Prediction of Discharge Status and Readmissions after Resection of Intradural Spinal Tumors.

OBJECTIVE: Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors. METHODS: IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset. RESULTS: A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n = 5,023, 99.3%) and tumors were most commonly found in the thoracic region (n = 1,941, 38.4%), followed by the lumbar (n = 1,781, 35.2%) and cervical (n = 1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%). CONCLUSION: Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

Risk Factors for Revision Surgery After Primary Adult Thoracolumbar Deformity Surgery.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term. METHODS: The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study. RESULTS: A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117). CONCLUSIONS: Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy.

BACKGROUND: There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care. OBJECTIVE: To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol. METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol. RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay. CONCLUSION: In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

Metastatic Paraganglioma of the Spine With SDHB Mutation: Case Report and Review of the Literature.

BACKGROUND: Paragangliomas (PGLs) are rare neuroendocrine tumors that can arise from any autonomic ganglion of the body. Most PGLs do not metastasize. Here, we present a rare case of metastatic PGL of the spine in a patient with a germline pathogenic succinate dehydrogenase subunit B (SDHB) mutation. METHODS: In addition to a case report we provide a literature review of metastatic spinal PGL to highlight the importance of genetic testing and long-term surveillance of these patients. RESULTS: A 45-year-old woman with history of spinal nerve root PGL, 17 years prior, presented with back pain of several months' duration. Imaging revealed multilevel lytic lesions throughout the cervical, thoracic, and lumbar spine as well as involvement of the right mandibular condyle and clavicle. Percutaneous biopsy of the L1 spinal lesion confirmed metastatic PGL and the patient underwent posterior tumor resection and instrumented fusion of T7-T11. Postoperatively the patient was found to have a pathogenic SDHB deletion. CONCLUSIONS: Patients with SDHx mutation, particularly SDHB, have increased risk of developing metastatic PGLs. Consequently, these individuals require long-term surveillance given the risk for developing new tumors or disease recurrence, even years to decades after primary tumor resection. Surgical management of spinal metastatic PGL involves correcting spinal instability, minimizing tumor burden, and alleviating epidural cord compression. In patients with metastatic PGL of the spine, genetic testing should be considered.

Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease.

STUDY DESIGN: This was an epidemiological study using national administrative data from the MarketScan database. OBJECTIVE: To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease. METHODS: We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes. RESULTS: A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574). CONCLUSIONS: When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To provide insight into postoperative complications, short-term quality outcomes, and costs of the surgical approaches of adult cervical deformity (ACD). METHODS: A national database was queried from 2007 to 2016 to identify patients who underwent cervical fusion for ACD. Patients were stratified by approach type-anterior, posterior, or circumferential. Patients undergoing anterior and posterior approach surgeries were additionally compared using propensity score matching. RESULTS: A total of 6575 patients underwent multilevel cervical fusion for ACD correction. Circumferential fusion had the highest postoperative complication rate (46.9% vs posterior: 36.7% vs anterior: 18.5%, P < .0001). Anterior fusion patients more commonly required reoperation compared with posterior fusion patients (P < .0001), and 90-day readmission rate was highest for patients undergoing circumferential fusion (P < .0001). After propensity score matching, the complication rate remained higher in the posterior, as compared to the anterior fusion group (P < .0001). Readmission rate also remained higher in the posterior fusion group; however, anterior fusion patients were more likely to require reoperation. At index hospitalization, posterior fusion led to 1.5× higher costs, and total payments at 90 days were 1.6× higher than their anterior fusion counterparts. CONCLUSION: Patients who undergo posterior fusion for ACD have higher complication rates, readmission rates, and higher cost burden than patients who undergo anterior fusion; however, posterior correction of ACD is associated with a lower rate of reoperation.

Optogenetic Stimulation Reduces Neuronal Nitric Oxide Synthase Expression After Stroke.

Post-stroke optogenetic stimulation has been shown to enhance neurovascular coupling and functional recovery. Neuronal nitric oxide synthase (nNOS) has been implicated as a key regulator of the neurovascular response in acute stroke; however, its role in subacute recovery remains unclear. We investigated the expression of nNOS in stroke mice undergoing optogenetic stimulation of the contralesional lateral cerebellar nucleus (cLCN). We also examined the effects of nNOS inhibition on functional recovery using a pharmacological inhibitor targeting nNOS. Optogenetically stimulated stroke mice demonstrated significant improvement on the horizontal rotating beam task at post-stroke days 10 and 14. nNOS mRNA and protein expression was significantly and selectively decreased in the contralesional primary motor cortex (cM1) of cLCN-stimulated mice. The nNOS expression in cM1 was negatively correlated with improved recovery. nNOS inhibitor (ARL 17477)-treated stroke mice exhibited a significant functional improvement in speed at post-stroke day 10, when compared to stroke mice receiving vehicle (saline) only. Our results show that optogenetic stimulation of cLCN and systemic nNOS inhibition both produce functional benefits after stroke, and suggest that nNOS may play a maladaptive role in post-stroke recovery.

Dual antiplatelet therapy after carotid artery stenting: trends and outcomes in a large national database.

BACKGROUND: While dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established. METHODS: We canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy. RESULTS: A total of 79 084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, <180 days prescribed post-CAS P2Y12-inhibition was associated with increased risk for stroke (<90 prescribed days HR=1.421, 95% CI 1.038 to 1.946; 90-179 prescribed days HR=1.484, 95% CI 1.045 to 2.106). The incidence of hemorrhagic complications was higher during the period of prescribed P2Y12-inhibition (1.16% per person-month vs 0.49% per person-month after discontinuation, P<0.001). The rate of extracranial hemorrhage was nearly six-fold higher while on dAPT (6.50% per patient-month vs 1.16% per patient-month, P<0.001), and there was a trend towards higher rate of intracranial hemorrhage that did not reach statistical significance (5.09% per patient-month vs 3.69% per patient-month, P=0.0556). Later hemorrhagic events beyond 30 days post-CAS were significantly more likely to be extracranial (P=0.028). CONCLUSIONS: Increased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.

Conventional versus stereotactic image guided pedicle screw placement during spinal deformity correction: a retrospective propensity score-matched study of a national longitudinal database.

PURPOSE/AIM: To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity. METHODS: The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses. RESULTS: A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups. CONCLUSIONS: Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.

Staged Surgical Resection of Brain Arteriovenous Malformations.

BACKGROUND: Staged treatment of brain arteriovenous malformations (AVMs) is sometimes necessary to minimize risks associated with sudden changes in cerebral hemodynamics. With the increasing availability and optimization of endovascular techniques, multiple surgical resections are rarely necessary, although, due to specific anatomic circumstances, some AVMs still require staged surgery. Here, we describe the largest reported series of staged surgical resections of brain AVMs. METHODS: This is a retrospective review of surgically resected AVMs at a single institution from 1998-2018. Patients who underwent ≥2 resections within 1 year were reviewed. Only those in whom initial resection was terminated with intention for further resection were included in analysis. RESULTS: Twenty patients underwent deliberately staged resection from 1998-2018. Average age at treatment was 36.2 years (SD 16.5 years). Eleven patients (55%) were female, and 12 (60%) had left-sided AVMs. Median Spetzler-Martin grade was 4 (interquartile range [IQR]: 3-4). Average AVM nidus diameter was 5.0 cm (SD 1.7 cm). Seven patients (35%) presented with AVM rupture, and 12 (60%) presented with focal neurologic deficits without hemorrhage. Seventeen patients (85%) underwent preoperative embolization, median number of embolizations was 3 (IQR: 2-4). Three patients (15%) underwent preoperative radiosurgery. Median number of days between surgeries was 28 (IQR: 8-41 days). Perioperative course was complicated by hemorrhage in 3 patients (15%); 1 required decompressive hemicraniectomy prior to the second stage of surgery. Good functional outcome (defined as modified Rankin Scale score ≤2) was achieved in 14 patients (70%). CONCLUSIONS: Staged surgical resection of large and complex AVMs can be performed with good outcomes in carefully selected patients.

Resection of Olfactory Groove Meningiomas Through Unilateral vs. Bilateral Approaches: A Systematic Review and Meta-Analysis.

Introduction: Consensus is limited regarding optimal transcranial approaches (TCAs) for the surgical resection of olfactory groove meningiomas (OGMs). This systematic review and meta-analysis aims to examine operative and peri-operative outcomes of unilateral compared to bilateral TCAs for OGMs. Methods: Electronic databases were searched from inception until December 2019 for studies delineating TCAs for OGM patients. Patient demographics, pre-operative symptoms, surgical outcomes, and complications were evaluated and analyzed with a meta-analysis of proportions. Results: A total of 27 observational case series comparing 554 unilateral vs. 451 bilateral TCA patients were eligible for review. The weighted pooled incidence of gross total resection is 94.6% (95% CI, 90.7-97.5%; I 2 = 59.0%; p = 0.001) for unilateral and 90.9% (95% CI, 85.6-95.4%; I 2 = 58.1%; p = 0.003) for bilateral cohorts. Similarly, the incidence of OGM recurrence is 2.6% (95% CI, 0.4-6.0%; I 2 = 53.1%; p = 0.012) and 4.7% (95% CI, 1.4-9.2%; I 2 = 55.3%; p = 0.006), respectively. Differences in oncologic outcomes were not found to be statistically significant (p = 0.21 and 0.35, respectively). Statistically significant differences in complication rates in bilateral vs. unilateral TCA cohorts include meningitis (1.0 vs. 0.0%; p = 0.022) and mortality (3.2 vs. 0.2%; p = 0.007). Conclusions: While both cohorts have similar oncologic outcomes, bilateral TCA patients exhibit higher post-operative complication rates. This may be explained by underlying tumor characteristics necessitating more radical resection but may also indicate increased morbidity with bilateral approaches. However, evidence from more controlled, comparative studies is warranted to further support these findings.

Evaluating the Impact of Spinal Osteotomy on Surgical Outcomes of Thoracolumbar Deformity Correction.

BACKGROUND: In cases of adult spinal deformity (ASD) with severe sagittal malalignment, the use of osteotomies may be necessary in addition to posterior fusion. However, few data exist describing the impact of osteotomies on complications and quality outcomes during ASD surgery. METHODS: We queried the MarketScan database to identify patients who underwent ASD surgery in 2007-2016. Patients were stratified according to whether or not an osteotomy was used in the index operation. Propensity score matching was used to mitigate intergroup differences between osteotomy and nonosteotomy groups. Patients <18 years old and patients with any prior history of trauma or tumor were excluded from the study. RESULTS: Of 7423 patients who met the inclusion criteria of this study, 2700 (36.4%) received an osteotomy. After propensity score matching, baseline comorbidities and approach type were similar between cohorts. The overall 90-day complication rate was 43.2% in the nonosteotomy group and 52.8% in the osteotomy group (P < 0.0001). The osteotomy cohort also had significantly higher rates of revision surgeries through 2 years (21.1% vs. 18.0%, P < 0.05) following index surgery. Patients who received a 3-column osteotomy had the highest procedural payments, costing $155,885 through 90 days and $167,161 through 1 year following surgery. CONCLUSIONS: This analysis confirms high costs and complication, readmission, and reoperation rates until 2 years after ASD surgery in general, which are even higher in cases where an osteotomy is required. Future research should explore strategies for optimizing patient outcomes following osteotomy.